Hypertension Case Study
C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.
PMHAllergic RhinitisDepressionHypothyroidismFamily HistoryFather died at age 49 from AMI: had HTNMother has DM and HTNBrother died at age 20 from complications of CFTwo younger sisters are A&WSocial HistoryThe patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.MedicationsZyrtec 10 mg dailyAllergiesPenicillinROSStates that his overall health has been fair to good during the past year.Weight has increased by approximately 30 pounds in the last 12 months.States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.Denies any nausea, vomiting, diarrhea, or blood in stool.Self treats for occasional right knee pain with OTC Ibuprofen.Denies any genitourinary symptoms.Vital SignsB/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.HEENTTMs intact and clear throughoutNo nasal drainageNo exudates or erythema in oropharynxPERRLAFunduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledemaNeckSupple without masses or bruitsThyroid normalNo lymphadenopathyLungsMild basilar crackles bilaterallyNo wheezesHeartRRRNo murmurs or rubsAbdomenSoft and non-distendedNo masses, bruits, or organomegalyNormal bowel soundsExtMoves all extremities wellNeuroNo sensory or motor abnormalitiesCN’s II-XII intactDTR’s = 2+Muscle tone=5/5 throughoutWhat you should do:Develop an evidence-based management plan.Include any pertinent diagnostics.Describe the patient education plan.Include cultural and lifespan considerations.Provide information on health promotion or health care maintenance needs.Describe the follow-up and referral for this patient.Prepare a 3–5-page paper (not including the title page or reference page).Assignment Requirements:Before finalizing your work, you should:be sure to read the Assignment description carefully (as displayed above);consult the Grading Rubric to make sure you have included everything necessary; andutilize spelling and grammar check to minimize errors.Your writing Assignment should:follow the conventions of Standard English (correct grammar, punctuation, etc.);be well ordered, logical, and unified, as well as original and insightful;display superior content, organization, style, and mechanics; anduse APA 6th Edition format as outlined in the APA Progression Ladder.